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Drug Sponsor Name
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Mennonite Mutual Aid Association
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Drug Plan Name
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Team Care Advantage Rx (H8836-001)
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Phone Number
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Current/Prospective Members: 1-800-348-7468 TTY/TDD: 1-888-858-8567
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Website
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www.mma-online.org
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Total monthly premium
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$36.00
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SPDAP monthly subsidy
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Up to $25 per month
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Monthly premium after subsidy
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$11.00
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Deductible
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$100.00
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1st tier copay
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$10.00
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2nd tier copay
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$35.00
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3rd tier copay
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$65.00
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4th tier copay, and description (such as injectibles, if applicable)
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25%
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Initial coverage limit [as defined in 42 CFR Part 423.104(d)(3)]
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$2,700.00
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Benefits available in coverage gap
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None
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Average drug price discount percentage below wholesale drug price available in coverage gap (for example, 95% equals a 5% price discount)
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Contact plan for details
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Mail order offered
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$20.00 for a 90-day supply of Generic drugs $70.00 for a 90-day supply of Preferred Brand drugs $130.00 for a 90-day supply of Non-Preferred Brand drugs 25% coinsurance for a 90-day supply of Specialty drugs
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Does this plan option’s formulary differ from plan sponsor’s other options
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Contact plan for details
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Medical management requirements (UM, PA)
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Contact plan for details
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MA-PD plan summary, including plan cost sharing for Part A & B benefits, and any supplemental benefits
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Contact plan for details
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Maryland SPDAP Coverage Gap Subsidy
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Not offered in this plan option
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Available in which Maryland Counties
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All counties in Maryland and Baltimore City
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